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The past century has seen vast improvements in our children's health. The infectious diseases that once killed huge numbers of children have largely been conquered. Infant mortality has also fallen markedly, although the United States lags behind other industrialized nations in this and other measures of children's health. Accidents and injuries also kill fewer children than they once did. Today, write Sara Rosenbaum and Robert Blum, the greatest threats to U.S. children's health are social and environmental conditions, such as stress and exposure to toxic substances, which are associated with noncommunicable illnesses, such as mental health problems and asthma. Unlike the communicable diseases of the past, these are not equal-opportunity hazards. They are far more likely to affect poor children and the children of racial and ethnic minorities. And they have long-lasting effects, both for individuals and for the nation. For example, people who experience unhealthy levels of stress as children grow up to become less healthy, less productive adults. Rosenbaum and Blum also examine government spending on children's health. Though such spending has increased over time, the largest share of that increased spending has been for health care, while spending on other determinants of child health, which may be as or more important, has not kept pace. Investments in medical care alone can't overcome social and environmental threats to children's health that have their roots in historic levels of poverty and inequality. Rosenbaum and Blum argue that the best way to promote children's health today is to mitigate poverty, invest in education, and make our neighborhoods and communities healthier and safer.

Background: Recent changes to Medicaid policy may have unintended consequences in the education system. This study estimated the potential financial impact of the Deficit Reduction Act (DRA) on school districts by calculating Medicaid-reimbursed behavioral health care expenditures for school-aged children in general and children in special education in particular. Methods: Medicaid claims and special education records of youth ages 6 to 18 years in Philadelphia, PA, were merged for calendar year 2002. Behavioral health care volume, type, and expenditures were compared between Medicaid-enrolled children receiving and not receiving special education. Results: Significant overlap existed among the 126,533 children who were either Medicaid enrolled (114,257) or received special education (27,620). Medicaid-reimbursed behavioral health care was used by 21% of children receiving special education (37% of those Medicaid enrolled) and 15% of other Medicaid-enrolled children. Total expenditures were $197.8 million, 40% of which was spent on the 5728 children in special education and 60% of which was spent on 15,092 other children. Conclusions: Medicaid-reimbursed behavioral health services disproportionately support special education students, with expenditures equivalent to 4% of Philadelphia's $2 billion education budget. The results suggest that special education programs depend on Medicaid-reimbursed services, the financing of which the DRA may jeopardize. (Contains 1 table and 3 figures.)